ADENOMYOSIS: CLINICAL FEATURES, INVESTIGATIONS, AND MANAGEMENT

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Gynecology / Feb 4th, 2026 1:35 pm A⁺ | a^-

BASIC INFORMATION:

Date & Time:

• 04 February 2026 | 00:31 IST

Lecture Handout Prepared from the Teaching Session by: Dr. R. K. Mishra

SUMMARY:

This lecture addresses adenomyosis within the broader series on abnormal uterine bleeding. Adenomyosis is defined as the ingrowth of endometrial tissue—containing both glandular and stromal components—into the myometrium to a depth greater than 2.5 mm. It is conceptually akin to endometriosis; however, the ectopic deposits in adenomyosis are located within the uterine muscle (endometriosis interna). The condition may be diffuse or focal; the focal variant is termed adenomyoma.

Adenomyosis predominantly affects women in their 40s with increased parity and a history of repeated uterine instrumentation (e.g., dilatation and curettage). Pathogenesis centers on disruption of the endometrial–myometrial interface (junctional zone), facilitating migration of endometrial glands and stroma into the inner myometrium. This ectopic tissue responds to ovarian steroids, leading to cyclical bleeding within the myometrium, tissue reaction, and myometrial hyperplasia, producing a globally enlarged, thick-walled uterus—often with posterior wall predominance.

Clinically, up to 50% may be asymptomatic. Symptomatic patients commonly present with menorrhagia (approximately 70%), progressive dysmenorrhea, dyspareunia, urinary frequency due to mass effect, and subfertility or miscarriages attributable to abnormal subendometrial myometrial function and retrograde myometrial contractions. Examination typically reveals a midline, globular, smooth-contoured uterus, usually not exceeding 12–14 weeks’ gestational size.

Diagnosis is primarily established by transvaginal ultrasonography using morphological uterus sonographic assessment (MUSA) criteria: posterior wall thickening, heterogeneous myometrial echotexture, subendometrial haze, myometrial cysts (honeycomb), and venetian blind (fan-shaped) shadowing. MRI is reserved for inconclusive cases and demonstrates junctional zone thickening (>12 mm), asymmetrical wall thickening (posterior > anterior), heterogeneous myometrium, and striated projections from endometrium into myometrium.

Management is guided by symptom severity and reproductive plans. NSAIDs are used for mild pain and bleeding. Hormonal therapies generally have limited efficacy; levonorgestrel-releasing intrauterine system (LNG-IUS, Mirena) can reduce menorrhagia and dysmenorrhea. Definitive treatment for parous women with completed family is total hysterectomy, commonly with bilateral salpingo-oophorectomy. Fertility-preserving options include adenomyomectomy for focal disease and uterine artery embolization in selected cases. The lecture emphasizes careful history taking, focused imaging evaluation, and individualized surgical decision-making.

KEY KNOWLEDGE POINTS:

Adenomyosis is endometrial gland and stroma ingrowth into the myometrium >2.5 mm (endometriosis interna).
More common in women in their 40s with increased parity and prior uterine instrumentation.
Pathogenesis involves disturbance of the junctional zone facilitating secondary infiltration into the inner myometrium.
Ectopic endometrium responds to ovarian steroids, causing myometrial bleeding, hyperplasia, and global uterine enlargement, often posteriorly predominant.
Cardinal symptoms: menorrhagia, progressive dysmenorrhea, dyspareunia, urinary frequency, subfertility, and miscarriages.
Examination: globular, smooth, midline uterine enlargement, typically up to 12–14 weeks’ size.
Ultrasound (TVS) signs: posterior wall enhancement, heterogeneous echotexture, subendometrial haze, myometrial cysts, venetian blind sign; MUSA criteria apply.
MRI: asymmetrical wall thickening, heterogeneous myometrium, myometrial cysts, striated projections, junctional zone thickening >12 mm.
Medical therapy limited; LNG-IUS may help. Definitive therapy is hysterectomy; conservative options include adenomyomectomy and uterine artery embolization.

INTRODUCTION:

Adenomyosis is a significant cause of abnormal uterine bleeding and pelvic pain. It represents the presence of endometrial glands and stroma within the myometrium, leading to structural and functional uterine changes. Distinct from pelvic endometriosis, adenomyosis is typically an affliction of multiparous women in their 40s and is frequently associated with prior uterine trauma or instrumentation. Understanding its pathophysiology—particularly the role of the endometrial–myometrial junctional zone—enables accurate diagnosis and targeted management.

LEARNING OBJECTIVES:

Define adenomyosis and distinguish it from endometriosis and leiomyoma.
Recognize clinical features and examination findings characteristic of adenomyosis.
Identify sonographic and MRI criteria for diagnosis and outline appropriate management strategies.

CORE CONTENT:

DEFINITION AND CLASSIFICATION
- Definition: Ingrowth of endometrial glandular and stromal tissue directly into the myometrium to a depth exceeding 2.5 mm.
- Classification:
  - Diffuse adenomyosis: Multiple deposits throughout the myometrium.
  - Focal adenomyosis (adenomyoma): Localized lesion resembling a fibroid but lacking a capsule (no pseudocapsule).
PATHOGENESIS
- Endometrial–Myometrial Interface (EMI)/Junctional Zone Disturbance:
  - The subendometrial myometrium (junctional zone) is normally hypoechoic and structurally distinct.
  - Breach of this zone permits migration of endometrial glands and stroma into inner myometrium.
- Predisposing Factors:
  - Multiple childbirths, repeated dilatation and curettage, genetic predisposition, and altered immune response.
- Hormonal Responsiveness:
  - Ectopic endometrium responds to estrogen and progesterone.
  - Functional layer involvement yields marked tissue reaction due to cyclical bleeding; basal layer involvement produces milder changes.
- Myometrial Reaction:
  - Hyperplasia with increased cell number and size; diffuse thickening and global uterine enlargement.
  - Posterior wall predominance (posterior enhancement) is common.
CLINICAL FEATURES
- Epidemiology and Risk Profile:
  - Elderly (perimenopausal) women in their 40s; increased parity; history of uterine instrumentation.
  - Pelvic endometriosis may coexist in approximately 40% of cases.
- Symptoms:
  - Menorrhagia (≈70%): due to increased uterine cavity, endometrial hyperplasia, and inadequate uterine contractions.
  - Progressive dysmenorrhea: colicky pain with retrograde/irregular myometrial contractions.
  - Dyspareunia; urinary frequency from mass effect in markedly enlarged uteri.
  - Infertility and miscarriages: abnormal subendometrial myometrial function, retrograde contractions impairing sperm transport and implantation; persistent immune disturbance.
- Physical Examination:
  - General: pallor may be present due to heavy bleeding.
  - Abdominal: hypogastric, midline, globular mass arising from the pelvis; smooth contour.
  - Pelvic (bimanual): enlarged, globular, thick-walled uterus, commonly 12–14 weeks size; global rather than irregular enlargement.
INVESTIGATIONS
- Ultrasonography (Transvaginal) – First-Line:
  - Myometrial Zonation: Inner (subendometrial) hypoechoic layer becomes hazy (loss of uniform hypoechogenicity).
  - Posterior Wall Enhancement: Increased thickness posteriorly compared to anterior wall.
  - Heterogeneous Myometrial Echotexture: Mixed hypo/hyperechoic areas.
  - Myometrial Cysts: Multiple small intramyometrial cysts producing honeycomb appearance.
  - Venetian Blind Sign: Fan-shaped hypoechoic bands extending from endometrium into posterior myometrium.
  - Ill-Defined Endometrial Echo: Blurring of endometrial–myometrial demarcation.
  - MUSA Criteria (Morphological Uterus Sonographic Assessment):
    - Posterior wall thickening.
    - Myometrial cysts.
    - Fan-shaped vascularity/venetian blind appearance.
    - Subendometrial halo alterations and diffuse infiltration.
    - Focal lesion with diffuse vascularity (adenomyoma).
- MRI – For Inconclusive Ultrasound:
  - Asymmetrical uterine wall thickening (posterior > anterior).
  - Heterogeneous myometrial signal; small myometrial cysts.
  - Striated projections from endometrium to myometrium (fan-shaped infiltrations).
  - Globally enlarged uterus.
  - Junctional zone thickening >12 mm.
MANAGEMENT
- General Principles:
  - Therapeutic approach based on symptom severity and reproductive desires.
  - Hormonal therapy overall has limited efficacy compared with endometriosis; LNG-IUS is an exception.
- Medical Management:
  - NSAIDs (e.g., ibuprofen) for mild dysmenorrhea and bleeding; symptomatic relief while approaching menopause when appropriate.
  - LNG-IUS (Mirena): Levonorgestrel-releasing intrauterine system provides sustained progestogenic effect; improves heavy bleeding and dysmenorrhea.
  - Agents with Little/Obsolete Role: Danazol is now largely obsolete in adenomyosis.
- Surgical Management:
  - Definitive: Total hysterectomy, commonly with bilateral salpingo-oophorectomy, for parous women with completed family; route individualized (abdominal or laparoscopic).
  - Conservative (Fertility-Preserving):
    - Adenomyomectomy: Excision of focal adenomyoma; differentiation from leiomyoma by absence of capsule and heterogeneous myometrial involvement; followed by myometrial repair.
    - Uterine Artery Embolization: Considered in selected cases; previously discussed in leiomyoma context.
    - Uterine Mass Reduction: Historical; limited current value.

SURGICAL PEARLS:

Practical tips based on surgical experience:
- Distinguish adenomyoma from leiomyoma intraoperatively by the lack of a pseudocapsule and diffuse infiltration into surrounding myometrium.
- When planning conservative surgery, ensure precise localization of focal disease to optimize adenomyomectomy outcomes and facilitate robust myometrial reconstruction.
- In definitive surgery for enlarged, globular uteri (12–14 weeks size), plan for adequate exposure and vascular control due to increased myometrial vascularity.
Common mistakes and how to avoid them:
- Misdiagnosis as fibroid due to globular mass; avoid by correlating with ultrasound signs (myometrial cysts, venetian blind sign, posterior wall enhancement).
- Overreliance on hormonal therapy; recognize limited efficacy and consider timely surgical intervention in refractory menorrhagia/dysmenorrhea.
- Ignoring fertility goals; explicitly assess patient’s reproductive plans before deciding between extirpative and conservative procedures.

ANESTHETIC AND PHYSIOLOGICAL CONSIDERATIONS:

Include only if discussed.

Not specifically discussed.

COMPLICATIONS AND THEIR MANAGEMENT:

Intraoperative:
- Not specifically detailed in the lecture.
Early postoperative:
- Not specifically detailed in the lecture.
Late postoperative:
- Not specifically detailed in the lecture.

MEDICOLEGAL AND PATIENT SELECTION CONSIDERATIONS:

Assess parity and reproductive intentions before recommending hysterectomy.
Document severity of symptoms, prior medical therapy, and imaging findings supporting adenomyosis diagnosis.
Counsel regarding limited medical options, potential benefits of LNG-IUS, and expectations from conservative surgery versus definitive hysterectomy.

SUMMARY AND TAKE-HOME MESSAGES:

Adenomyosis involves endometrial gland and stroma ingrowth into the myometrium, often with posterior predominance.
Menorrhagia and progressive dysmenorrhea are hallmark symptoms; examination reveals a globular, smooth, midline uterine enlargement typically up to 12–14 weeks.
Transvaginal ultrasonography is diagnostic in most cases; MRI is reserved for inconclusive studies and demonstrates junctional zone thickening and asymmetrical wall involvement.
Hormonal therapy has limited efficacy; LNG-IUS can ameliorate bleeding and pain. Definitive management is hysterectomy for parous women; adenomyomectomy and uterine artery embolization are options for focal disease and fertility preservation.

MULTIPLE CHOICE QUESTIONS (MCQs):

Adenomyosis is defined as ingrowth of endometrial tissue into the myometrium to a depth greater than:
- A. 1.0 mm
- B. 2.5 mm
- C. 5.0 mm
- D. 10 mm
- Correct answer: B
Adenomyosis is commonly seen in:
- A. Adolescents with primary dysmenorrhea
- B. Nulliparous women in their 20s
- C. Women in their 40s with increased parity
- D. Postmenopausal women only
- Correct answer: C
The focal form of adenomyosis is called:
- A. Leiomyoma
- B. Adenomyoma
- C. Endometrial polyp
- D. Submucous fibroid
- Correct answer: B
A typical examination finding in adenomyosis is:
- A. Irregular, nodular uterine enlargement
- B. Globular, smooth, midline uterine enlargement
- C. Unilateral adnexal mass
- D. Cervical polyp
- Correct answer: B
Posterior wall predominance in adenomyosis is often attributed to:
- A. Anterior vascular supply
- B. Gravity-related posterior enhancement
- C. Cervical stenosis
- D. Ovarian torsion
- Correct answer: B
The junctional zone primarily refers to:
- A. Endocervical canal
- B. Subendometrial myometrium at the endometrial–myometrial interface
- C. Peritoneal reflection over the uterus
- D. Serosal layer of the uterus
- Correct answer: B
On transvaginal ultrasound, the inner myometrial layer in adenomyosis typically shows:
- A. Uniform hyperechogenicity
- B. Subendometrial haze with loss of uniform hypoechogenicity
- C. Anechoic fluid collection only
- D. Calcifications exclusively
- Correct answer: B
The venetian blind sign on ultrasound refers to:
- A. Linear calcifications in the endometrium
- B. Fan-shaped hypoechoic bands extending into the myometrium
- C. Shadowing from submucous fibroids
- D. Doppler aliasing artifact
- Correct answer: B
The presence of multiple small myometrial cysts on ultrasound suggests:
- A. Endometrial polyp
- B. Adenomyosis
- C. Ovarian cystadenoma
- D. Tubo-ovarian abscess
- Correct answer: B
A globally enlarged uterus on imaging is more typical of:
- A. Adenomyosis
- B. Subserous fibroid
- C. Endometrial carcinoma
- D. Ovarian hyperstimulation
- Correct answer: A
MRI criterion supportive of adenomyosis includes junctional zone thickness:
- A. <5 mm
- B. 6–8 mm
- C. >12 mm
- D. >20 mm
- Correct answer: C
The most frequent presenting symptom in adenomyosis is:
- A. Amenorrhea
- B. Menorrhagia
- C. Postcoital bleeding
- D. Intermenstrual spotting only
- Correct answer: B
Dysmenorrhea in adenomyosis is typically:
- A. Non-cyclical
- B. Progressive and colicky during menses
- C. Always absent
- D. Only mid-cycle
- Correct answer: B
Infertility in adenomyosis is plausibly related to:
- A. Ovarian failure
- B. Abnormal subendometrial myometrial function and retrograde contractions
- C. Tubal occlusion only
- D. Cervical incompetence
- Correct answer: B
Differentiation of adenomyoma from leiomyoma intraoperatively is aided by:
- A. Presence of a pseudocapsule in adenomyoma
- B. Absence of a capsule and diffuse infiltration in adenomyoma
- C. Calcification pattern unique to adenomyoma
- D. Pedunculated attachment in adenomyoma
- Correct answer: B
First-line imaging modality for suspected adenomyosis is:
- A. CT scan
- B. Hysterosalpingography
- C. Transvaginal ultrasonography
- D. PET-CT
- Correct answer: C
Hormonal therapy in adenomyosis generally:
- A. Cures the disease
- B. Has limited efficacy compared to endometriosis
- C. Is contraindicated
- D. Is the definitive treatment
- Correct answer: B
The levonorgestrel-releasing intrauterine system (LNG-IUS) in adenomyosis:
- A. Worsens menorrhagia
- B. Is ineffective for pain
- C. Can reduce heavy bleeding and dysmenorrhea
- D. Is used only for contraception
- Correct answer: C
Definitive treatment for parous women with completed family and severe adenomyosis is:
- A. Endometrial ablation
- B. Total hysterectomy (commonly with BSO)
- C. Cervical cerclage
- D. Bilateral tubal ligation only
- Correct answer: B
Uterine artery embolization in adenomyosis is:
- A. Never indicated
- B. Only for malignancy
- C. A conservative option in selected cases
- D. Replaces hysterectomy universally
- Correct answer: C

MOTIVATIONAL MESSAGE FROM DR. R. K. MISHRA:

“In surgery, precision is born from disciplined learning, and patient safety is the measure of our mastery. Every careful decision in the clinic prepares your hands for the operating room.”

Wishing you clarity in judgment, skill in execution, and unwavering commitment to your patients. Keep progressing with purpose.